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Overview

Address
57 PROSPECT STREET, NANTUCKET, MA 02554
Phone
(508) 228-1200
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
Birthing Friendly
Yes
Star rating not available
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 2 of 7 measures reported
2
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Readmission 6 of 11 measures reported
5
1
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Timely & Effective Care 9 of 12 measures reported
9 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure 46 discharges
1.0493 p78
Pneumonia 70 discharges
1.0353 p73
COPD
— Not reported
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
Expected (1.0) National median

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.0493
Value-Based Purchasing
HAC Reduction
No Reduction

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE
Hybrid_HWM 4.10 No Different Than the National Rate 137
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD Number of Cases Too Small
MORT_30_HF 12.50 No Different Than the National Rate 37
MORT_30_PN 13.10 No Different Than the National Rate 73
MORT_30_STK Number of Cases Too Small
PSI_03 0.57 No Different Than the National Rate 351
PSI_04
PSI_06 0.21 No Different Than the National Rate 495
PSI_08 0.27 No Different Than the National Rate 471
PSI_09 Number of Cases Too Small
PSI_10
PSI_11
PSI_12 Number of Cases Too Small
PSI_13
PSI_14
PSI_15 Number of Cases Too Small
PSI_90

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 87%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 3%
H_COMP_1_U_P: Nurses "usually" communicated well 10%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 93%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 5%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 87%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 5%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 8%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 81%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 3%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 16%
H_COMP_2_A_P: Doctors "always" communicated well 88%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 4%
H_COMP_2_U_P: Doctors "usually" communicated well 8%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 93%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 1%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 6%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 88%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 4%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 8%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 82%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 7%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 11%
H_COMP_5_A_P: Staff "always" explained 75%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 15%
H_COMP_5_U_P: Staff "usually" explained 10%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating
H_MED_FOR_A_P: Staff "always" explained new medications 84%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7%
H_MED_FOR_U_P: Staff "usually" explained new medications 9%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 65%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 24%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 11%
H_COMP_6_N_P: No, staff "did not" give patients this information 9%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 91%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 8%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 92%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 10%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 90%
H_CLEAN_HSP_A_P: Room was "always" clean 81%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 6%
H_CLEAN_HSP_U_P: Room was "usually" clean 13%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating
H_QUIET_HSP_A_P: "Always" quiet at night 73%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 4%
H_QUIET_HSP_U_P: "Usually" quiet at night 23%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 3%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 10%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 87%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 3%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 78%
H_RECMND_PY: "YES", patients would probably recommend the hospital 19%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating
H_STAR_RATING: Summary star rating

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER
HAI_1_CIUPPER
HAI_1_DOPC 96.000
HAI_1_ELIGCASES 0.055
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER
HAI_2_CIUPPER
HAI_2_DOPC 101.000
HAI_2_ELIGCASES 0.049
HAI_2_NUMERATOR 0.000
HAI_2_SIR
HAI_3_CILOWER
HAI_3_CIUPPER
HAI_3_DOPC
HAI_3_ELIGCASES
HAI_3_NUMERATOR
HAI_3_SIR
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC
HAI_4_ELIGCASES
HAI_4_NUMERATOR
HAI_4_SIR
HAI_5_CILOWER
HAI_5_CIUPPER
HAI_5_DOPC 2412.000
HAI_5_ELIGCASES 0.043
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER
HAI_6_CIUPPER
HAI_6_DOPC 2148.000
HAI_6_ELIGCASES 0.390
HAI_6_NUMERATOR 0.000
HAI_6_SIR

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV low Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER Electronic Clinical Quality Measure
HH_HYPO Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 99.0 Healthcare Personnel Vaccination
OP_18a 112.0 Emergency Department
OP_18b 105.0 Emergency Department
OP_18c 278.0 Emergency Department
OP_18d 404.0 Emergency Department
OP_22 0.0 Emergency Department
OP_23 Emergency Department
OP_29 100.0 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 10.0 Electronic Clinical Quality Measure
SEP_1 50.0 Sepsis Care
SEP_SH_3HR Sepsis Care
SEP_SH_6HR Sepsis Care
SEV_SEP_3HR 72.0 Sepsis Care
SEV_SEP_6HR Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 97.0 Electronic Clinical Quality Measure
VTE_2 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI Number of Cases Too Small
EDAC_30_HF 103.90 More Days Than Average per 100 Discharges
EDAC_30_PN 6.70 Average Days per 100 Discharges
Hybrid_HWR 15.10 No Different Than the National Rate
OP_32 12.50 No Different Than the National Rate
OP_35_ADM 10.30 No Different Than the National Rate
OP_35_ED 6.20 No Different Than the National Rate
OP_36 1.00 No Different than expected
READM_30_AMI Number of Cases Too Small
READM_30_CABG
READM_30_COPD Number of Cases Too Small
READM_30_HF 20.60 No Different Than the National Rate
READM_30_HIP_KNEE
READM_30_PN 16.50 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.76

Financial Health (Cost Report — FY 2023)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.58 metrics.cost_to_charge_ratio
Cost Report Current Ratio 2.30 metrics.current_ratio
Cost Report Employees per Bed 14.36 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Fund Balance ($) $152,284,805 metrics.fund_balance
Cost Report Net Income ($) $-4,003,158 metrics.net_income
Cost Report Net Patient Revenue ($) $77,400,376 metrics.net_patient_revenue
Cost Report Operating Margin (%) -15.2% metrics.operating_margin
Cost Report Total Assets ($) $165,768,475 metrics.total_assets
Cost Report Total Costs ($) $72,818,519 metrics.total_costs
Cost Report Total Liabilities ($) $13,483,670 metrics.total_liabilities
Cost Report Total Margin (%) -4.7% metrics.total_margin
Cost Report Uncompensated Care (%) 4.6% metrics.uncompensated_care_pct
General Information Address 57 PROSPECT STREET Address
General Information City/Town NANTUCKET City/Town
General Information Count of Facility MORT Measures 2 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures Not Available Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 6 Count of Facility READM Measures
General Information Count of Facility Safety Measures Not Available Count of Facility Safety Measures
General Information Count of Facility TE Measures 9 Count of Facility TE Measures
General Information Count of MORT Measures Better 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 2 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 0 Count of READM Measures Better
General Information Count of READM Measures No Different 5 Count of READM Measures No Different
General Information Count of READM Measures Worse 1 Count of READM Measures Worse
General Information Count of Safety Measures Better Not Available Count of Safety Measures Better
General Information Count of Safety Measures No Different Not Available Count of Safety Measures No Different
General Information Count of Safety Measures Worse Not Available Count of Safety Measures Worse
General Information County/Parish NANTUCKET County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 220177 Facility ID
General Information Facility Name NANTUCKET COTTAGE HOSPITAL Facility Name
General Information Hospital overall rating Not Available Hospital overall rating
General Information Hospital overall rating footnote 16 Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote 5 Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote 5 Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State MA State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (508) 228-1200 Telephone Number
General Information ZIP Code 02554 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program payment_reduction No payment_reduction
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 0.76 Value
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.05 0.9983 p78 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 17.8% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 46 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 12 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.6% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.04 0.9955 p73 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 13.4% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 70 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 12 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 13.9% READM-30-PN-HRRP.predicted_readmission_rate
Methodology

Full methodology →